HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 58 PADDOCK LANE 8/5/2024 P�ao�ec
Commonwealth of Massachusetts �o �
City/Town of �° � �-L%
S System Pumping Record e'N
Form 4
DEP has provided this form for use by local Boards of Health. Other fo ' iay be used, but the
information must be substantially the same as that provided here. 8efo using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: frontClacl)ide rear left* right
A. Facility Information BUILDING: fron ide rear right
Important:when DECK: under
filling out forms 1. System Location:
the computer,
use
use only the tab
key to move your Address
cursor•do not r—
use the return Cil !Town �L�Q� MA O s y�
key. y Slate Zip Code
W,011 2. System Owner:
Name
rnan
Address (if different from location)
____ MA
CIIyfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ogle Z� L 2 Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
06`Mc.
6. System Pumped By:
Dave Tiney Ma s 1AA95E Mass 1AD31Z
Name Veh le License Nu ber
Bateson Enterprises, Inc.
Company
7. rL
n where contents were disposed:
�-It Z
Signa ure of Hauler Dale
Signature of Receiving Facility(orretlach facility receipt) Date
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